Smoking Cessation Questionnaire Please complete the following, then click submit. Name* First Last Today's Date* MM DD YYYY Age*Occupation*Is Your Work Stressful?*NoModeratelyVeryPartner's NameChildren's Name(s) and Ages if applicableDo others in your family smoke?*NoYesHow many cigarettes do you smoke in a day?*At what age did you start smoking?*Why did you start? (check all that apply) Peer Pressure To Rebel Against Authority To Appear More Adult Other If you selected "Other" reasons, please describe here.What do you "get" from smoking? (check all that apply)* It relaxes me It gives me a confidence boost It helps me concentrate Something to do with my hands (a prop) An excuse to take a break Other When do you smoke? (check all that apply)* While walking At breakfast On breaks With coffee, etc. After meals When driving On the phone At work In bed Other What frightens you about smoking?Do you know someone who has died from a smoking related disease?What is important to you?Who are you important to? Why?Has your doctor mentioned your smoking?Have you had any worrisome symptoms? Please describe.Do you have any health problems? (check all that apply) Heart problems High blood pressure Diabetes Asthma Ulcers Other How long do you want to live? Why?Who is responsible for your health?What will you be able to do as a non-smoker that you could not do before? Please describe.Do you really wish to commit yourself to stopping smoking?Who has stopped you?Name, address and phone of your regular physician:Is thre anything else you wish your hypnotherapist to know?